Based on previous papers (33, 38, 39), this study could create and validate the COVID-19 Bullying Scale (CBS-11), an 11-item easy-to-understand tool used to measure bullying towards COVID-19 patients in adults. It also evaluated the rate of bullying and assessed the related factors among a sample of Lebanese adults.
The CBS-11 showed to be efficient, with an average completion time of five minutes. Its internal consistency was high in our sample, indicating that the scale is reliable. Also, the convergent validity with other used scales was appropriate, and the correlation of the items with CBS-11 displayed favorable results. The factor analysis of CBS-11 showed that all items had high loadings on one factor, reflecting a robust factorial validity. Moreover, Cronbach’s alpha value was high. These results indicate that CBS-11 is a valid and reliable tool to assess bullying toward COVID-19 patients among the general adult population, which could help in research and clinical practice. However, our findings were not comparable to those in the literature since there is no bullying scale available to be used among adults during an infectious disease, and CBS-11 was created especially for this study; hence the need for further studies to confirm our results.
Bullying is a global public health problem mainly prevalent among students and labor forces (59), expected to increase during lockdowns due to the increased tensions between individuals (60). In our study, 59.3% of participants reported having experienced bullying during this pandemic, a high proportion that cannot be compared to any other results as, to date, no research has yet evaluated bullying toward COVID-19 among the general population. However, a study among 7411 healthcare from 173 countries found that 8.0% of the participants experienced COVID-19-related harassment, bullying, or hurt (37). Other available studies are related to bullying among adolescents, where the prevalence ranges from 8–55% (28, 61–64). The high rate of bullying found in our study could be due to the type of scale used to measure bullying, different from those previously used among adolescents (33, 39). Also, contextual characteristics of surrounding communities could have influenced bullying behaviors and the perception of people with an infectious disease (65, 66). For example, the family could be considered a protective factor and might play a role in bullying prevention (67). Lebanon and other Arab countries share common cultural values such as power gap, ambiguity avoidance, and masculinity (68). Some Arab families might protect their members from bullying, while others might reinforce behaviors that expose their children to bullying (25).
Our results revealed that those who have discrimination attitudes exhibit more bullying behaviors toward COVID-19 patients. It is well known that bullying and discrimination have several similar and overlapping characteristics (69). Both can happen once or repeatedly over time. Both depend on the imbalances between the person who engages in the act of bullying and the target (69). Epidemic outbreaks such as HIV/AIDS, severe acute respiratory syndrome (SARS), Ebola virus disease, and Zika virus have historically been accompanied by discrimination and negative attitudes toward the infected persons (70). A study conducted in an urban Southern Africa setting showed an association between stigma, bullying, and mental health in people with HIV (71). Another clinical-based study of HIV-positive adolescents found that HIV-related stigma and bullying were associated with major depressive disorder and a high risk of suicidality (72).
In our study, a higher fear of COVID-19 was significantly associated with the presence of bullying, likely due to increased coronavirus-induced anxiety, resulting from news updates about complications and death reports from COVID-19 (73). Fear of COVID-19 substantially increases negative feelings such as anxiety and depression (74). In response to this fear of disease and death, people tend to blame others; they also engage in gossips and spread rumors and misconceptions (74). An online study of 3551 non-healthcare workers in the US and Canada revealed that a high percentage of Canadians and Americans believed that healthcare workers should not be allowed to go out in public, should have restrictions on their freedoms, should be isolated from the community, and separated from their families .
In our study, participants with a history of COVID-19 in the family had lower bullying levels, contrary to previous findings showing that US adults who experienced COVID-19 (e.g., being diagnosed with COVID-19 or knowing people with COVID-19) were more likely to have cyberbullying behaviors (75). Moreover, an Iranian study among 1498 participants found that having a family member with COVID-19 was associated with higher anxiety levels (76). Our results support the idea that the family might be supportive and might play a protective role against bullying, particularly after acquiring sufficient knowledge about the disease, thus reducing unfavorable psychological effects due to COVID-19. Social support helps individuals to cope with the negative effects of the disease by mitigating anxiety and fear. A systematic review of meta-analyses unveiled the most important protective factors against bullying and cyberbullying in the community, school, family, and peers, showing that having a family member in the medical field increases bullying acts (77). Similarly, a study has reported that healthcare workers are more subject to harassment and bullying (37, 77).
Our results showed that adherence to prevention strategies and recommendations was related to higher bullying, contrary to previous findings showing that the fewer healthcare workers adhere to the prevention measures, the more exposed they were to COVID-19 bullying (37). One explanation for our results could be that people wearing masks and adhering to the protective measures in public and crowded places are subject to bullying and intimidation by those who deny coronavirus and are opposed to hygiene measures. Further studies are needed to elucidate these discrepancies.
Anxiety due to COVID-19 mediated the association between knowledge and bullying scale in our study. No similar framework exploring the relationships between these factors is available in the literature. Most studies investigate psychological pathways between adolescents and bullying (28, 78, 79). Psychological distress can result from a lack of awareness and misconceptions regarding COVID-19 (80–82). Further studies are needed to identify factors that promote and mediate the bullying process of individuals.
Moreover, our study showed that the female gender was associated with lower bullying compared to males. Bullying has been described as a gendered phenomenon (83). In England, more than one-quarter of males (26.9%) and one-in-seven females (14.8%) reported that they had bullied others (84). A study in Taiwan evaluating the prevalence of school bullying among secondary students showed higher bullying rates in male students compared to female students (85). Every society categorizing people according to sex assigns specific expectations that are part of the gender social construction (86). Lebanon is described as a patriarchal country, where men have the authority and power, thus explaining our results (87). Also, it could be that both genders exhibit bullying but under different forms; boys are more likely to express physical bullying behaviors such as hitting and fighting while girls usually engage in indirect bullying such as teasing, gossiping, or spreading rumors (88).
Strengths and Limitations
This study was the first to provide an insight into bullying among a sample of adults from the general population. It can serve to create new research questions or hypotheses about drivers for bullying and related factors. However, it has several limitations. Its cross-sectional design does not allow us to infer causality between bullying and the associated variables, essentially fear, anxiety, and stigma toward COVID-19. The fact that data were gathered online using a self-reported questionnaire could have generated an information bias. However, to reduce this kind of bias, we have used odd-numbered response categories with a neutral option, allowing the participants to opt-out and give an indifferent response, resulting in a non-differential measurement error instead of a differential information bias. The link to the survey was only available for a few days; it is therefore advisable to continue collecting data to explore changes in mental health over time. The sample size was not big enough to generalize to the whole population. The snowball technique used to collect the data is a nonrandom technique that could generate a selection bias. The bullying scale was created especially for this study and was not yet validated. Residual confounding bias is also possible since some bullying-related factors such as personality traits, aggressiveness, and family support, were not assessed in this study. Lastly, there are very few studies on bullying in adults, making it impossible to compare our results with those in the literature.